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  1. After Harm: Medical Error and the Ethics of Forgiveness. | PSNet

    psnet.ahrq.gov/issue/after-harm-medical-error-and-ethics-forgiveness
    July 24, 2019 - Book/Report After Harm: Medical Error and the Ethics of Forgiveness. … Citation Text: After Harm: Medical Error and the Ethics of Forgiveness. Berlinger N. … URL Cite Citation Citation Text: After Harm: Medical Error … July 24, 2019 Talking with Patients and Families about Medical Error: A Guide for Education

  2. The threat within: mitigating the risk of medical error. | PSNet

    psnet.ahrq.gov/issue/threat-within-mitigating-risk-medical-error
    July 15, 2020 - Book/Report The threat within: mitigating the risk of medical error. … The Threat Within: Mitigating The Risk Of Medical Error. … The Threat Within: Mitigating The Risk Of Medical Error. … March 24, 2021 Developing open disclosure strategies to medical error using simulation … December 15, 2021 Hearing impairment and the amelioration of avoidable medical error:

  3. The wrong foot, and other tales of surgical error. | PSNet

    psnet.ahrq.gov/issue/wrong-foot-and-other-tales-surgical-error
    January 18, 2023 - Newspaper/Magazine Article The wrong foot, and other tales of surgical error. … Citation Text: The wrong foot, and other tales of surgical error. Altman LK. New York Times.  … Cite Citation Citation Text: The wrong foot, and other tales of surgical error

  4. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - The purpose of voluntary medication error reporting is to identify these sources of error. … Medication Error Report Data The MEDMARX program assigns a unique record number to each error report … 28.4 22.6 6.0 B Error occurred but it did not reach the patient 14.9 23.9 40.9 C Error occurred … a The number of error types exceeds the number of reports for severity Categories B – I because error … Type of Error Omission and improper dose/quantity were the two most frequently reported error types,

  5. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
    January 01, 2004 - to the overall error rate found in the prescription error studies. … error-reduction practices might affect error rate. … be an inefficient way to reduce error when the error rate already is quite low. … Several error-reduction practices had surprisingly low error-reduction scores. … Error reporting also receives a low score when it is treated as an error reduction practice.

  6. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
    March 21, 2008 - or no error, and categorized the error according to the International Taxonomy of Errors in Primary … ” and “error.” … error occurred. … Frequency of error by type of medication management and type of error Type of medication management … If detected, an error might require additional effort (mitigation transactions) to resolve the error

  7. Sterile water should not be given "freely." | PSNet

    psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
    March 18, 2010 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  8. Final Progress Report: Enhancing the Disclosure Of Medical Errors to Patients (pdf file)

    www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdf
    January 01, 2024 - , but 42 percent would explicitly state that an error occurred. … mentioned the error compared with 32 percent who received the less-apparent error. … In addition to his empiric work in error disclosure, Dr. … Physicians’ and Nurses’ Perspectives on Error Reporting in Hospitals. … Content of medical error disclosures. Virtual Mentor. March 2004.

  9. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. | PSNet

    psnet.ahrq.gov/issue/characteristics-pediatric-chemotherapy-medication-errors-national-error-reporting-database
    September 21, 2008 - Study Characteristics of pediatric chemotherapy medication errors in a national error … Characteristics of pediatric chemotherapy medication errors in a national error reporting database. … May 20, 2020 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 Eric Cropp weighs in on the error that sent him to prison.

  10. Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee. | PSNet

    psnet.ahrq.gov/issue/error-avoidance-recommendations-tubing-misconnections-when-using-luer-tip-connectors
    November 21, 2018 - May 17, 2023 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  11. Internally-developed online adverse drug reaction and medication error reporting systems. | PSNet

    psnet.ahrq.gov/issue/internally-developed-online-adverse-drug-reaction-and-medication-error-reporting-systems
    July 12, 2010 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  12. Supervision, autonomy, and medical error in the teaching clinic. | PSNet

    psnet.ahrq.gov/issue/supervision-autonomy-and-medical-error-teaching-clinic
    November 26, 2014 - Commentary Supervision, autonomy, and medical error in the teaching clinic. … Supervision, autonomy, and medical error in the teaching clinic. … Supervision, autonomy, and medical error in the teaching clinic.

  13. Ashamed to admit it: owning up to medical error. | PSNet

    psnet.ahrq.gov/issue/ashamed-admit-it-owning-medical-error
    April 03, 2019 - Commentary Ashamed to admit it: owning up to medical error. … Ashamed to admit it: owning up to medical error. … Ashamed to admit it: owning up to medical error.

  14. Communication skills and error in the intensive care unit. | PSNet

    psnet.ahrq.gov/issue/communication-skills-and-error-intensive-care-unit
    May 06, 2009 - Review Communication skills and error in the intensive care unit. … Communication skills and error in the intensive care unit. Curr Opin Crit Care. 2007;13(6):732-6. … Communication skills and error in the intensive care unit. … December 21, 2011 Patient safety: helping medical students understand error in healthcare

  15. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs024755-hettinger-final-report-2019.pdf
    January 01, 2019 - This methodology included data driven error pattern detection, point of error video capture and retrieval … Cases were assigned as an unlikely error, a possible error, and a highly likely error. … A generous cut-off is four hours, if > four hours, it is an unlikely error Point of Error 1. … Interruption Error? … DATA DRIVEN ERROR PATTERN DETECTION 2. POINT OF ERROR VIDEO CAPTURE AND RETRIEVAL 3.

  16. A Conceptual Model for Disclosure of Medical Errors (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
    January 01, 2004 - Error factors included level of harm and whether patients and others were aware of the error and the … The level of harm caused by the error and whether patients and others were aware of the error and any … You put yourself in the hands of your professional…” Error factors The outcome of the error—who … Error outcome and patient awareness of the error outweighed any other determinants for disclosure related … to the error itself.

  17. Using Home Visits to Understand Medication Errors in Children (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
    May 28, 2008 - the error. … error without injury). 3. … Not a medication error (excluded from the study). 10 A medication error is an error in drug ordering … Was a possible error found? … Was anyone notified of the error?

  18. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
    November 29, 2004 - , a lipid-control error, or a pharmacy error. … : (a) glycemic-control error; (b) lipid-control error; or (c) pharmacy error. … N % Error N % Error status unknown N % A1c < 7% At goal 1,371 33.0% A1c 7 – 7.9% … Column C provides the error rate in the subgroup at risk, while column D provides the error rate in … another type of error.

  19. Learning from Errors in Ambulatory Pediatrics (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
    February 01, 2004 - Error reports were then read to ensure that each report represented a mutually exclusive error. … Reports that included more than one error were divided into separate error reports. … Examples of error reports Medical domain categories Example error report Preventive Medicine “ … Examples of error reports, cont. … Error discovered.

  20. Disclosure of Errors | PSNet

    psnet.ahrq.gov/primer/disclosure-errors
    September 15, 2024 - Background Many patients harmed by a medical error never learn of the error. … Increasing the amount and quality of error disclosure will require addressing physician discomfort with … This may also require changes in how organizations approach error disclosure. … disclosure of an error may be admissible in a malpractice lawsuit. … There is some evidence that formal training in error disclosure can improve physicians' comfort with
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